END OF

LIFE
Importance of End
of Life Care
To relieve the suffering of the
patient and their families by the
comprehensive assessment and treatment
of physical, psychosocial and spiritual
symptoms patients experience.

2
4 - Goals of End of Life

 To keep pain to the minimum using clinical

method.
 To treat symptoms and improve health when
possible.
 To assist with mobility and safety
 To allow meaningful interaction between patient,
their friends, families and community
3
Palliative
Care

4
DEFINITION OF PALLIATIVE CARE

Geriatric palliative care: the approach to care for the chronically ill and frail elderly.
The focus is on quality of life, support for functional independence, and centrality of the
patient's values and experiences in determining the goals of medical care (Morrison &
Meier, 2003).

Geriatric palliative care is integrative using interdisciplinary delivery of care. The

goal to relieve pain and suffering and improve quality of life for elderly patients and their
families. The core principles are comprehensive patient/family unit centered that enhance
functional independence and quality of life transitioning between levels of care (Morrison
& Meier, 2003). 5
  PALLIATIVE CARE

i. Provides relief from pain and other distressing symptoms;

ii. Affirms life and regards dying as a normal process;

iii. Intends neither to hasten or postpone death;

iv. Integrates the psychological and spiritual aspects of patient care;

v. offers a support system to help patients live as actively as possible until

death; 6
  PALLIATIVE CARE

vi. Offers a support system to help the family cope during the patient’s illness and in their
own bereavement;

vii. Uses a team approach to address the needs of patients and their families, including
bereavement counselling, if indicated;

viii. Will enhance quality of life, and may also positively influence the course of illness; ix.
is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes those
investigations needed to better understand and manage distressing clinical
complications. (World Health Organization, 2017)
7
 AUTONOMY

The state of being self-governed thinking and acting

independently without outside influence and direction.
 BEREAVEMENT
The state of having suffered the death of someone significant.
 GRIEF
Reactions experienced in anticipation of during and a loss.
8
Models of
Palliative
Care
9
 1. Palliative Approach - Primary
• Population approach, organizational

• Client group have varying degree of need for the palliative approach

• Identify the transition markers • Essentially holistic approach

• Extending beyond routine care

• Incorporating specific knowledge, attitudes and skills

• Establish a supportive relationship with specialist palliative care providers • Involving

family and friends 10
 2. Specialist – Tertiary
• Interdisciplinary consultative team

• Support and consultation

• Direct assessment - collaborative care planning

• Rationalizes complex problems

• Clinical treatment as necessary

• Research/education

11
 Indication for Specialist Consultations

 Exacerbation of previously stable symptoms

 Needs exceed the capacity of the facility

 Client requires complex symptom management

 Risk of complications, physical - social –emotional 12

 3) End-of-life – Terminal

• Dying trajectory

• Goal more focused on existential issues - meaning, affirmation of

life, spiritual comfort

• Unfinished business - forgiveness - reconcile

• Family/friends needs for comfort and information

13
 3) End-of-life –Terminal

• Anticipatory grief
• Physiological signs - palliative treatment
• Meticulous physical care - including symptom
control
• Consider the environment of care
• Spiritual care - rituals, ceremonies etc.
14
RECOGNIZING
TRANSITION
MARKERS

15
 A. Non-Disease Specific Indicators
1. FRAILTY – extreme vulnerability to morbidity and mortality due to progressive decline
in function and physiological reserve. Frequent falls, disability, susceptibility to acute illness
and reduced ability to recover are examples of frailty.

2.FUNCTIONAL DEPENDENCE – dependence on others to perform activities of

daily life.

3. COGNITIVE IMPAIRMENT – changes in memory, attention, thinking, language,

praxis, and executive.

4. FAMILY SUPPORT NEEDS – emotional support, information and educational support

unique to each patient/family and/or caregivers. 16
B. Disease Specific Markers
1. Symptomatic CHF

2. Dementia

3. Stroke

4. Cancer

5. Recurrent infections

6. Degenerative joint disease causing functional impairment and

chronic pain 17
 C. COMMON SYMPTOMS IN GERIATRIC
PALLIATIVE CARE
1. DYSPNEA IN PALLIATIVE
CARE

18
A. Definition of Dyspnea

 Difficult or labored breathing; shortness of breath

 Dyspnea is a subjective experience described as an

uncomfortable awareness of breathing,
breathlessness, or severe shortness of breath
19
B. Potential Causes of Dyspnea

1. Debility with aging adult: Anemia, atelectasis, pulmonary embolism, pneumonia,

emphysema, cachexia-anorexia syndrome, or weakness (asthenia).

2. Disease with increased age: COPD, asthma, CHF, acidosis, angina, respiratory
infection.

3. Cancer complications: Pleural effusions, bronchial obstruction, metastasis, superior

vena cava syndrome, tumor replacing normal lung tissue, lymphangitis carcinomatosis,
mediastinal obstruction, pericardial effusion, massive ascites, or abdominal distention.
20
4. Complications of treatment of primary disease: Congestive
heart failure secondary to chemotherapy or constrictive
pericarditis related to radiation therapy, radiation induced
fibrosis, or anemia secondary to chemotherapy.

5. Psychological disorders: anxiety, depression, panic disorders

(Dickerson, Benedetti, Davis et al., 2001).

21
C. Assessment of Dyspnea
 Assessment should start with using the patient’s descriptor of how they are feeling, e.g.
breathlessness, need to gasp or pant, unable to get enough air, feeling like suffocating (Morrison &
Meier, 2003; Kazanowski, 2003) and asking the following regarding descriptor: (Morrison & Meier,
2003)

 Onset (days, weeks, hours) or acute vs. chronic

 What makes it better or worse

 What does it feel like – further assess descriptor

 Other symptoms occurring with it pain, chest tightness, palpitations, cough, fever, lightheadedness
22
 How severe is it (using a scale such as Visual Analog Scale 1-10)? How much does it
interfere with daily life and function?

 When is it at its worst? Is it always present or does it come and go? Are there any
temporal factors (night vs. daytime)?

 If patient unable to answer ask caregiver their observations of the above questions.
Review of the past history for potential underlying causes of dyspnea, e.g., COPD,
CHF, renal failure or lung cancer (Kazanowski, 2003) and review list of medications.
23
Physical Exam:
~ General appearance – mental status (is it different than normal?) Can patient speak a
complete sentence without stopping?

~ Count respiratory rate accurately, note use of accessory muscles or not

~ Examine skin, cardiac (is there an S3 or murmur), respiratory status (are breath sound
decreased, crackles or rhonchi/wheezing present?) and look for signs of infection or
dehydration.

~ Oxygen saturation resting and after walking (if able)

24
 D. Management of Dyspnea

Goal of managing dyspnea in the palliative care patient is to

ensure the best quality of life (Morrison & Meier, 2003).

25
General Treatments:
•Reduce the need for exertion and arrange for readily available help (e.g. access to call light,
caregiver at bedside).

•Reposition, usually more upright position or with the compromised lung down.

•Improve circulation: provide draft-fans, open windows. Adjust humidity with humidifier or
air conditioner.

•Identify and address situational components that trigger dyspnea.

26
General Treatments:

•Address anxiety (consider anti-anxiety agent) and provide reassurance.

•Discuss the meaning of symptoms and other patient and family concerns.

•Teach behavioral interventions such as relaxation, hypnosis.

•Discuss family concerns about use of opioids to relieve dyspnea.

•Provide oxygen, many will feel better with saturation > 90%.
27
Non-Pharmacological Interventions :

•Facilitate circulation of air – electric fans or air-conditioning.

•Positioning patient to facilitate chest expansion – head of bed elevated with feet
flat or down, upper body leaning forward supported with pillows.

•Oxygen therapy: O2 2-6L NP, reassess q2hr after each change of flow.

•Cooling off the body.

28
Non-Pharmacological Interventions :

•Conservation of patient energy.

•Offer Foley catheter if dyspnea with voiding or patient on diuretics for

dyspnea.

•Pursed lip breathing.

•Complementary therapies: imagery, massage, breathing exercises,

therapeutic touch, music, aromatherapy, relaxation exercises.
29
2. DEPRESSION IN PALLIATIVE
CARE

30
A. Assess for Depression Risk Factors

•Uncontrolled pain

•Multiple co-morbid issues and associated deficits: inability to walk, loss of bowel and
bladder control, amputation, inability to eat or swallow, sensory loss, exhaustion.

•Medical co morbidity: Cancer patients at highest risk are those diagnosed with oral,
pharyngeal, or lung

•Recent conflict or a loss of significant relationship

•Familiar history, prior episodes of depression, suicide attempt
•Lack of social support
•Feelings of being burden to family 31
3. FATIGUE IN PALLIATIVE CARE

 "an overwhelming, sustained sense of exhaustion and decreased capacity for

physical or emotional work"(Tiesinag,Dassen & Halfens, 1996). Described by
patients as worn out, exhausted sleepiness, tired, low energy and care
providers as lethargy or malaise (Morrison & Meier, 2003).

32
CRITERIA OF FATIGUE IN PALLIATIVE CARE:

o A subjective perception
o Alteration in neuromuscular and metabolic processes o
Decrease in physical performance
o Deterioration in mental and physical activities
o •Feelings of being burden to family
33
 4. NAUSEA / VOMITING

 Consider dietary modification (bland, soft, adjust timing/ volume of

foods)

 Aromatherapy – peppermint, lavender, acupuncture

 Constipation – increase fiber in diet, encourage fluid

34
5. ORAL LESION / DYSPHAGIA

 Oral hygiene

 Appropriate liquid, solid, and oral medication formulation (texture,

taste , fluidity )

 Treat infections, complication (mucositis, pharyngitis, dental abscess,

esophagitis )

 Orophayryngeal motility study and speech consultation.

35
 6. ANOREXIA

 Manage treatable lesions causing oral plain, dysphagia, and anorexia

 Support caloric intake during phase of illness when anorexia is

reversible •

 Prevent / treat coexisting constipation

36
 7. PRURITUS
o Moisturize skin

o Try specialized anti-itch lotions

o Apply cold packs

o Counter stimulation, distraction and relaxation

37
PROVIDING
COMFORT FOR
THE
TERMINALLY
ILL CLIENT
38
a. Symptom Control – Comfort for a dying patient requires management of symptoms of disease
and therapies.

b. Maintain Dignity and Self Esteem – when a patient is diagnosed with a terminally ill condition,
their dignity and self-esteem decrease.

c. Prevent Abandonment and Isolation - many terminally ill clients are fearful of dying alone. it
is important that a nurse establish a presence and inquire about the client concern, be available to
answer question.

d. Provide Comfortable and Peaceful Environment - is a part of holistic healing and help client
to relax which promotes their ability to sleep and minimize severity of symptoms.

e. Address Fears of Dying and Death - People are afraid of dying and death for many different
reasons 39
HOW TO GET
FAMILY
INVOLVED IN
CARE

40
1. Be the primary caregiver for the client if preferred.

2. Discuss activities other family members are involved in

3. Inquire about client’s concern

4. During final moments family can visit frequently

5. Allow home-cooked meals, which may be preferred by client and gives the family a chance to
participate in care.

6. Find simple and appropriate care activities for family to perform.

7. Bring in pictures, cherished objects.

8. Offer client frequent massage or other forms of therapeutic care. 41

Nurse Teaching
Strategies for
Family
Involvement
42
1. Describe / demonstrate feeding technique, bathing, mouth care.

2. Enforce clients rest periods, creating a visiting schedule

3. Discuss ways to support the dying person by listening to the needs

and fears of bathe client.

4. Demonstrate therapeutic touch.

5. Teach signs / symptoms of worsening condition 43

Eight Domains of
Palliative Care

44
1) Structure and Processes of Care

Emphasis is given on interdisciplinary team’s (IDT)

engagement and collaboration with patients and families; and on
coordinated assessment and continuity of care across healthcare
settings. Clarity and specificity of interdisciplinary team
composition, team member qualifications, necessary education,
training and support are described. 45
2) Physical Aspects of Care

Emphasis is given on the assessment and treatment of physical

symptoms with appropriate validated tools. Management of
symptoms is multidimensional with pharmacological,
interventional, behavioral and complementary interventions. The
utilization of explicit policies for the treatment of pain and
symptom management, as well as safe prescribing of controlled
medication is recommended. 46
3) Psychological Aspects of Care

Focus is given on the collaborative assessment process of

psychological concerns and psychiatric diagnoses. Essential
elements are described and include patient-family
communication on assessment, diagnosis and treatment options
for common conditions in context of respect for goals of care of
the patient and family. New to this domain is the description and
required elements of a bereavement program. 47
4) Social Aspects of Care

Emphasis is given on the interdisciplinary engagement and

collaboration with patients and families to identify, support and
capitalize on patient and family strengths. Essential elements of
palliative care social assessment are defined. The role of the
professional social worker is also described.

48
5) Spiritual Aspects of Care

This domain includes definition of spirituality, stressing assessment, access

and staff collaboration in attending to spiritual concerns throughout the illness
trajectory. Requirements for staff training and education in provision of
spiritual care are offered. There is stronger emphasis on the responsibility of
the IDT, inclusive of an appropriately trained chaplain to explore, assess and
attend to spiritual issues of the patient and family. The domain promotes
spiritual and religious rituals and practices for comfort and relief. 49
6) Cultural Aspects of Care

This domain defines “culture” and cultural competence for the

IDT, underscoring culture as a source of resilience and strength
for the patient and family. This accentuates cultural and linguistic
competence including plain language, literacy, and linguistically
appropriate service delivery.

50
7) Care of the Imminently Dying

This domain highlights communication and documentation of signs and

symptoms of the dying process in the circle of care: the patient, the family,
and all other involved health providers. The importance of meticulous
assessment and management of pain and other symptoms is highlighted.
Essential attention is given to family guidance as to what to expect in the
dying process and post death period. Bereavement support that begins with
anticipatory grief in the period before the actual death and continues through
the actual death is stressed. 51
8) Ethical & Legal Aspects of Care

This domain is restructured into three sections:

a. Advance Care Planning:

Emphasis on responsibility of the palliative care team to promote ongoing discussion about goals
of care along with completion and documentation of advance care planning documents.

52
b. Ethics:
The acknowledgement and affirmation of the frequency and complexity of ethical issues in the
palliative care. Team competencies in the identification and resolution of commonly encountered
ethical issues are described, with the importance of seeking advice and counsel from ethics
committees.

c. Legal Aspects of Care:

Acknowledgement of the complex legal and regulatory issues that arise in palliative care. There is
new emphasis on the necessity of and access to expert legal counsel, essential for navigating the
intricate and sensitive legal and regulatory issues in palliative care.

53
GUIDELINES FOR
QUALITY PALLIATIVE
CARE BY DOMAIN

54
a. Psychological Aspects of Care
1. The IDT assesses and addresses psychological and psychiatric aspects of care based upon the best
available evidence to maximize patient and family coping and quality of life.

CRITERIA:
• Includes professionals with skills and training in the potential psychological and psychiatric
impact of serious or life-threatening illness, on both the patient and family including depression,
anxiety, delirium and cognitive impairment.

• • Assessment of psychological needs, and promoting adjustment to the physical condition

or illness.

• • Regular, ongoing assessment of psychological reactions related to the illness and

psychiatric conditions is documented.
55
• Educating the patient and family about the disease, symptoms, side
effects and treatment as well as caregiving needs, decision making
capacity and coping strategies, provision of safe and appropriate
psychological measures supportive to the patient, from the family.

• Staff education includes recognition and treatment of common

psychological and psychiatric syndromes as well as professional coping
strategies to manage anticipatory grief and loss.
56
2. A core component of the palliative care program is a grief and
bereavement program available to patients and families based on
assessment of need.

Criteria:
• IDT includes professionals with patients

57
c. Cultural Aspects of Care

1. The palliative care program serves each patient, family and community in a culturally
and linguistically appropriate manner.

Criteria:

• Culture is multidimensional and implies the integrated pattern of human behavior that
includes thoughts, communications, actions, beliefs, values and institutions of racial, ethnic,
religious and social group.
• During assessment process, the IDT elicits and documents cultural identification, strengths,
concerns, and needs of the patient and family, realizing that cultural identity and expression vary
within families and communities.
• The plan of care addresses these cultural concerns and maximizes their cultural strengths.
58
•The team must convey respect to cultural perceptions, preferences, and practices
regarding illness, disability, treatment, help seeking, disclosure, decision making,
grief, death, dying and family composition.

• Palliative care staff communicates in a language and manner understandable by

the patient and family:

• Tailored to level of literacy, health, financial literacy and numeracy.

• Accommodate dietary and ritual practices.

• Identify community resources that serve various cultural groups and gives
referrals as appropriate.
59
2. The palliative care program strives to enhance its cultural and linguistic
competence.

• Cultural competence: process by which individuals and systems respond

respectfully and effectively to people of all cultures and languages in a manner that
recognizes, affirms and values the worth of individuals, families and communities.

• Palliative care values diversity and creates a work environment that affirms
multiculturalism.

• Staff members cultivate cultural self-awareness and recognize how their own
cultural values, beliefs, biases, and practices inform their perceptions of patients,
families and colleagues. 60
Physical Changes
Nearing Death
and Associated
Definitions
61
1. Mottling – near death, circulation decreases causing hands and feet to
become blotchy and purplish

62
2. Rigor Mortis – the stiffening of the body prior to death.

63
3. Shroud - sheet like garment for wrapping a corpse for burial

64
4. Cheyne-stokes – abnormal pattern of breathing characterized by
alternating periods of suspended breathing and deep rapid breathing or no
breathing. Indicator that death is near.

65
Care of the
Body After
Death
66
 POST MORTEM
an examination of a body after death. All deceased children and
adults are treated with respect while being provided end-of-life care.
Family members are allowed to participate in the activities to complete
end-of-life care needs. Religious practices, cultural rituals and any
other requests are taken into consideration.

67
 POSTMORTEM CARE
is the care provided to a patient immediately after death. Registered
Nurses, Licensed Practical Nurse and other Health Care Providers are
responsible for ensuring that all aspects of post mortem care are
completed.

68
Assessment of Death Situation:

1.) Verify that patient has been pronounced dead by

the physician.
2.) Identify cadaver, and collect his/her belongings
for labeling

69
Planning:
1.) Collect necessary equipment:
a. Bathing supplies
b. Shroud or morgue bag
c. 3-Identification tag (toe, wrist and cadaver bag)
d. Roll of gauze
e. Paper or plastic bag for personal belonging
f. Morgue cart
2.) If visitors are in the room, carefully explain the situation and ask them to
temporarily leave the room if possible.
3.) Follow the hospital procedure regarding the notification of various departments
70
and personnel.
Four Stages
of Death

71
1. Pallor Mortis – paleness of death
Increased paleness in the face and other part due to cessation of blood circulation.

72
2. Algor Mortis –cool of death
Reduction in body temperature following death.

73
3. Rigor Mortis – death stiffness
sign of death caused by chemical changes in the muscles after death, causing the limbs
of the corpse to become stiff and difficult to move or manipulate.

74
4. Livor Mortis- Settling of the blood in the lower portion of
the body, causing a purplish red discoloration of the skin.

75
 Post Mortem Care Procedure

1. Straighten limbs before death, if possible place head on pillow

2. Remove tubes

3. Replace soiled dressings

4. Pad anal area

76
 Post Mortem Care Procedure

5. Gently wash the body to remove discharge

6.Place body on back with head and shoulder elevated
7. Grasp eyelashes and gently pull lids down

8. Insert dentures if any

9.Place clean gown on body and cover with clean sheet.

10. Note time of death and chart
11. Notify Attending physician-chart any special directions.

12. Notify family members – allow time with loved one

77
Post Mortem Care Procedure
13. Gather eyeglasses and other belongings

14. Prepare necessary paper work for body removal.

15. Call funeral home for body transport

16. Note on chart:

a.) What personal artifacts were released with the body.
b.) What belonging were released
c.) Who received the belongings.

17. Tag or provide identification as per policy.

78
 Thanks!
“Death is a challenge. It tells us not to waste time… It tells us to tell
each other right now that we love each other.”

79